PERSONAL HEALTH; A New Set of Knees Comes at a Price: A Whole Lot of Pain

By JANE E. BRODY

Published: February 8, 2005

Total knee replacement is now one of the nation's leading orthopedic operations, and it promises to become even more popular as the population ages (and grows heavier) and the body's most vulnerable joints fail to withstand the punishment of decades of use and abuse.

Debilitating wear-and-tear arthritis is the major reason that knee bones are being replaced by two-pound pieces of metal in people who wish to remain mobile, pain-free and physically active in their later years.

Dozens of people I know who've endured the surgery say it has changed their lives very much for the better. They can walk again with comfort, even play tennis and ski, after years of sitting on the sidelines.

The Time Was Right

And so, at age 63, I decided to have both knees replaced. I had been nursing my increasingly arthritic knees and bowed legs for two decades -- at first with ice packs and ibuprofen whenever I did strenuous activity, graduating to daily Vioxx and Tylenol with growing limits on what I could do without life-limiting discomfort.

The last straw (after giving up tennis, ice skating and cross-country skiing) was my inability to hike or even join my friends on our morning fitness walk around the park. Even Vioxx (before it was withdrawn from the market) was not keeping me comfortably on my feet.

I consulted one of the world's leading orthopedic surgeons, a man who had done thousands of knee and hip replacements, including 500 double knees. He was very reassuring.

With the aid of physical therapy, he said, I could expect to be driving again in four weeks and well on the way to full recovery in six. Even the reputedly horrific postoperative pain associated with this surgery, he added, is now fully controlled with morphine through epidural anesthesia supplemented by extra doses that the patients can administer.

A neighbor who had one knee replaced last summer had warned me, ''The first four weeks are hell,'' but I discounted her prediction, given that I was in good health, top physical condition and slender going into the surgery.

A preoperative education session at the hospital emphasized the importance of good pain control because without it patients cannot do the physical therapy essential to a good recovery.

I gave two preoperative blood donations (one for each knee), arranged for inpatient rehabilitation after leaving the hospital and thought I was fully prepared for what lay ahead.

Facing Reality

I was not prepared for the swelling. When I arrived at the rehab center on the fourth postoperative day, I weighed in at 120, 15 pounds more than I weighed at surgery.

My legs were filled with fluid, hard as rocks, with no visible bones, veins or tendons. In four days I was down to 103, but my legs continued to swell and stiffen for more than two months.

As for pain, the surgeon was right on one count: the morphine was bliss -- not a bit of pain the first two days after the operation. Then it was withdrawn and replaced by two narcotic oral pain medications, which worked pretty well for about five days.

But as the various tissues in my knees began to heal and physical therapy got more demanding, the pain grew worse and worse, until at three weeks I found myself moaning, then crying for much of the day despite the narcotics and repeated icing of my swollen knees. Sleep was my only relief, but one can't do that 24/7.

Thinking something must be radically wrong, I returned to the surgeon 26 days after the operation, only to be told my knees looked perfect on X-rays and that my mobility placed me in the top 2 percent on the recovery scale: I could walk and go up and down stairs, albeit slowly, and I could fully extend my knees and bend them 90 degrees.

As reassuring as this assessment was, it did nothing to control my pain. So he changed my medication to a potent anti-inflammatory drug and suggested that I gradually cut back on the narcotics. That proved to be something of a pipe dream, at least for the next several weeks. And there was no sleeping without a nightly dose of Ambien.

I learned much later that I could have been prescribed a much higher dose of narcotics with no ill effect and much better pain control. No doctor I reported to, however, including the surgeon, even considered that.

The fact is, This operation, which involved cutting my leg bones to straighten my bowed legs, hurts like hell. To the few patients I spoke with who had relatively little postoperative pain, I say, ''Count your blessings.''

My biggest complaint was not that I was suffering. (The pain at five weeks after the operation had definitely eased on most days, although my right knee hurt much more than the left. So much for driving!) My biggest complaint was that I hadn't been warned. I was presented only with the best-case result, not the worst.

Too Sore to Knit

I complained to my internist that in the first three postoperative weeks all I had been able to do was read three simple novels. Even knitting and crocheting seemed too much for me, let alone the many projects I'd hoped to tackle during my self-assigned six-week recovery period.